Chronic diseases and health promotion

Part Three. What works: the evidence for action

Chapter Two. Review of effective interventions

Rehabilitation. Spotlight: India, Pakistan

Chronic diseases are major causes of disability, including blindness, lower limb amputation, motor and sensory dysfunction following stroke, chronic pain, and impaired functioning following myocardial infarction. Rehabilitation is intended to enable people to continue to live full lives as part of society. In some conditions, notably after myocardial infarction, rehabilitation reduces mortality. Multidisciplinary and intensive rehabilitation programmes, common in high income countries, are typically not feasible in low and middle income countries. However, community-based rehabilitation can provide effective rehabilitation in these countries.

Evidence of effectiveness

  • Rehabilitation services for patients following a stroke and living at home can improve independence.
  • Multidisciplinary rehabilitation services in patients with chronic low back pain can reduce pain and improve function.
  • Cardiac rehabilitation (following myocardial infarction), with a focus on exercise, is associated with a significant reduction in mortality.

Providing rehabilitation services in developing countries

Rehabilitation services are usually provided by a team of specialized personnel, including medical doctors, dentists, prosthetists, physio-therapists, occupational therapists, social workers, psychologists, speech therapists, audiologists and mobility instructors. In many low and middle income countries, this rehabilitation approach is not feasible owing to shortages of health workers and other resource constraints.

In these situations, community-based rehabilitation is a viable alternative, using and building on the community's resources as well as those offered at district, provincial and central levels. Community-based rehabilitation is implemented through the combined efforts of people with disabilities, their families, organizations and communities, as well as the relevant governmental and nongovernmental health, education, vocational, social and other services. Such efforts are being made in more than 90 (mostly low and middle income) countries. The focus has expanded to health care, education, livelihood opportunities and participation/inclusion. As an overall approach, it has not been rigorously evaluated but site-specific evidence is generally positive.

Spotlight: Community-based rehabilitation in India

In rural south India, permanently blind people were supported with community-based rehabilitation. This included mobility training and training to perform normal daily activities. Quality of life improved for some 95% of participants.

Spotlight: Community-based rehabilitation in Pakistan

In Pakistan, volunteer local supervisors from targeted communities (villages and slum areas) were taught to identify and train people with disabilities. One to two years after training, 80% of participants showed improvement in function.